Cited by 664Dementia and Cognitive Impairment ResearchAlzheimer's disease research and treatmentsNeuroinflammation and Neurodegeneration Mechanisms

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Neuropathology of nondemented aging: Presumptive evidence for preclinical Alzheimer disease

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Abstract

Objective To determine the frequency and possible cognitive effect of histological Alzheimer’s disease (AD) in autopsied older nondemented individuals. Design Senile plaques (SPs) and neurofibrillary tangles (NFTs) were assessed quantitatively in 97 cases from 7 Alzheimer’s Disease Centers (ADCs). Neuropathological diagnoses of AD (npAD) were also made with four sets of criteria. Adjusted linear mixed models tested differences between participants with and without npAD on the quantitative neuropathology measures and psychometric test scores prior to death. Spearman rank-order correlations between AD lesions and psychometric scores at last assessment were calculated for cases with pathology in particular regions. Setting Washington University Alzheimer’s Disease Research Center. Participants Ninety-seven nondemented participants who were age 60 years or older at death (mean = 84 years). Results About 40% of nondemented individuals met at least some level of criteria for npAD; when strict criteria were used, about 20% of cases had npAD. Substantial overlap of Braak neurofibrillary stages occurred between npAD and no-npAD cases. Although there was no measurable cognitive impairment prior to death for either the no-npAD or npAD groups, cognitive function in nondemented aging appears to be degraded by the presence of NFTs and SPs. Conclusions Neuropathological processes related to AD in persons without dementia appear to be associated with subtle cognitive dysfunction and may represent a preclinical stage of the illness. By age 80–85 years, many nondemented older adults have substantial AD pathology.

Overview

AI snapshot

Written from the paper’s full text.

TL;DR

In 97 nondemented older adults autopsied across seven Alzheimer’s Disease Centers, a substantial minority had Alzheimer-type neuropathology, and higher plaque or tangle burden was linked to slightly poorer cognitive scores despite no clinical dementia. The results support the possibility of a presymptomatic Alzheimer stage, though the study cannot prove that these cases would have progressed.

Key findings

  • Depending on the criteria used, 39–47% of cases met some neuropathological AD threshold; stricter thresholds identified about 19–21%. Khachaturian criteria classified 47%, Washington University criteria 39%, CERAD any level 39% (19% possible, 19% probable, 2% definite), and NIA-Reagan any level 39% (20% low, 16% intermediate, 3% high).
  • Cases with and without neuropathological AD did not differ in age at death, interval from last assessment to death, education, or last psychometric performance.
  • Among cases with lesions in the relevant regions, greater AD pathology correlated with worse performance on episodic memory, category fluency, Trailmaking A and B, and the MMSE; neocortical diffuse senile plaque density best discriminated neuropathological AD from no neuropathological AD.
  • Braak stages ranged from 0 to V with a median of II. Older age correlated with higher Braak stage (r = .372, p < .001), limbic NFT density increased with age (r = .437, p < .001), plaque burden did not correlate with age (r = .089, p = .40), and neocortical plaque burden was weakly related to limbic NFT density (r = .196, p = .07).

Methods

  • The sample included 97 autopsied nondemented participants aged 60 or older at death (mean 84.3 ± 8.6 years; 55 women; mean education 15.4 ± 2.9 years; mean last MMSE 28.1 ± 2.1) from 7 Alzheimer’s Disease Centers, all with CDR 0 within 2 years of death; 11 CDR > 0 cases were assessed but not reported.
  • A central laboratory processed five brain regions uniformly, used silver and immunohistochemical stains, made consensus diagnoses with four criteria sets (Khachaturian, Washington University, CERAD, NIA-Reagan), assigned Braak stages, and quantified plaques and tangles using computerized stereology.
  • Analyses used linear mixed models adjusted for center and covariates, ROC/sensitivity analyses for diffuse plaques, and Spearman correlations between lesion densities and last psychometric scores.

Limitations

  • The authors state that the study used a convenience sample, could not assess genotype effects, had small samples for some cognitive associations, and faced variability in initial fixation and tissue processing across centers. They also note that plaques and tangles may be downstream of the pathogenic processes causing synaptic and neuronal degeneration, and that the study did not address early protein changes, later neuronal or synaptic loss, vascular lesions, or synucleinopathy.
  • The authors caution that findings from nondemented individuals may not extend to cases with manifest dementia, and that missing psychometric data and small numbers with both lesions and test results require interpretive caution.
  • Evident from the text: the cross-sectional autopsy design cannot establish whether pathology precedes or predicts dementia, and correlations weakened when all cases were included or when adjusting for age or education.

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Integrity signals

Registry

Crossref · 10.1016/j.neurobiolaging.2009.04.002

Cites

64 of 64 references verified0 citation errors · 0 not checkable

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Claims the paper makes

41 Own result · 32 Not checked yet · 16 Own method · 12 Own interpretation · 1 No basis given

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  • Probably not a substantial claim. 31
  • It may state two separate claims as one. 26
52 of 52
  • The paper relies on this without support.

    The autopsied sample from seven Alzheimer Disease Centers is representative of nondemented older adults in the general population.

    “By age 80–85 years, many nondemented older adults have substantial AD pathology.”
  • The paper relies on this without support.

    The observed associations between Alzheimer disease lesions and cognitive test scores are not due to other brain pathologies or unmeasured confounders.

    “In all cases, greater pathology was associated with poorer cognitive performance at last assessment on measures of episodic memory (Logical Memory Delayed), semantic knowledge (Category Fluency), visuospatial ability (Trailmaking A), and executive function (Trailmaking B) as well as on a general measure, the MMSE.”
  • The paper relies on this without support.

    The four published neuropathological criteria validly classify neuropathological Alzheimer disease in nondemented older adults even though they were developed for dementia.

    “Each case was assessed in accordance with 4 published criteria for the neuropathological diagnosis of AD.”
  • The paper relies on this without support.

    The autopsy sample of nondemented older adults is representative enough that the estimated frequency of npAD applies to nondemented older adults generally.

    “The finding that up to 40% of nondemented individuals with a mean age of death of 84 years have npAD corresponds with some estimates of the prevalence of clinically apparent DAT in this age group.(Hebert et al., 2003)”
  • The paper relies on this without support.

    The cognitive deficits associated with AD lesions in nondemented individuals are attributable to those lesions rather than to other pathologies or measurement error.

    “This study did not address the early protein changes that lead to SPs and NFTs or the later synaptic or neuronal loss and other potential factors (e.g., vascular lesions; synucleinopathy) that could contribute to cognitive dysfunction; for example, SPs and NFTs may elicit a host response that contributes to the neurotoxicity of AD.(Castellani et al., 2008)”
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Metadata

Authors
Price, J. L., McKeel, D. W., Buckles, V. D., Roe, C. M., Xiong, C., Grundman, M., Hansen, L. A., Petersen, R. C., Parisi, J. E., Dickson, D. W., Smith, C. D., Davis, D. G., Schmitt, F. A., Markesbery, W. R., Kaye, J., Kurlan, R., Hulette, C., Kurland, B. F., Higdon, R., Kukull, W., & Morris, J. C.
Affiliations
  • Washington University in St. Louis (US)
  • Elan Pharmaceuticals, Inc. (Ireland) (IE)
  • University of California San Diego (US)
  • Mayo Clinic (US)
  • University of Kentucky (US)
  • Central Baptist Hospital (US)
  • Oregon Health & Science University (US)
  • University of Rochester Medicine (US)
  • Duke University (US)
  • Fred Hutch Cancer Center (US)
  • University of Washington (US)
Corresponding author
Morris, John C.
Venue
Neurobiology of Aging
Publisher
Elsevier BV
Published
2009-07
Volume
30
Issue
7
Pages
1026-1036
ISSN
0197-4580 (ISSN-L)
OpenAlex
W2114222094
Cited by
661
References
65
Citations by year
2026: 17 · 2025: 17 · 2024: 21 · 2023: 29 · 2022: 31 · 2021: 38 · 2020: 30 · 2019: 37 · 2018: 48 · 2017: 34 · 2016: 54 · 2015: 49 · 2014: 47 · 2013: 38 · 2012: 60
FWCI
34.43
Type
journal article
Language
en
Open access
Locations
  • Neurobiology of Aging (publishedVersion)
  • PubMed (publishedVersion)
  • Europe PMC (PubMed Central) (acceptedVersion)
  • PubMed Central (acceptedVersion)
Funders
  • National Institutes of Health (UL1TR000448)
  • National Institute on Aging (P30AG028383, P30AG028377, U01AG016976, P50AG005131, P30AG008017, U01-AG 16976, P 50 AG05681, P50AG005681, P01 AG0 3991, P01AG003991, P30AG008665, P01AG026276, P50AG016574)
  • National Center for Research Resources (UL1RR024992)
  • National Center for Advancing Translational Sciences
Topics
  • Health Sciences › Medicine › Psychiatry and Mental health › Dementia and Cognitive Impairment Research
  • Life Sciences › Neuroscience › Cellular and Molecular Neuroscience › Alzheimer's disease research and treatments
  • Life Sciences › Neuroscience › Neurology › Neuroinflammation and Neurodegeneration Mechanisms
Keywords
preclinical Alzheimer's disease, Alzheimer's disease pathology, amyloid plaques, neurofibrillary tangles, cognitive impairment, older adults
MeSH terms
Aged, Aged, 80 and over, Aging, Alzheimer Disease, Brain, Cognition Disorders, Female, Humans, Male, Middle Aged, Neuropsychological Tests, Psychometrics, Severity of Illness Index, Statistics as Topic, Linear Models, Neurofibrillary Tangles, Age Distribution, Disease Progression, Early Diagnosis, Plaque, Amyloid

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